Caring for The Dying Patient

Caring for a dying patient presents a unique set of circumstances that do not exist in any other situation.

Know thyself

First you have to understand and come to grips with your own feelings about death and dying.

• Try to remain objective even if you’ve known the patient for a long time and have become somewhat attached. Don’t let your emotions rule your decisions.

• Don’t second-guess your previous decisions on the case. There is a natural tendency for us to be thinking, “What should I have done differently to avoid this?” While it’s always good to try to learn something from every situation, you have to remember that you made the best decisions you could based on the information you had at the time. In most cases the physician’s guilt stems from his/her overwhelming sense of responsibility for the care of the patient. This guilt is usually unreasonable, since the physician didn’t cause the dying state; the disease did. We sometimes forget that.

• Some physicians have a tendency to withdraw from dying patients either because the patient represents a “failure” in that physician’s ability to keep them alive, or because the physician has a fear of his/her own mortality. You have to remember that dying is the natural order of life, just as birth is. We all have to do this sometime. We need to come to grips with our own mortality before we can face someone else’s.

Understanding and knowledge

Second, try to understand and empathize with the dying patient’s position. Think about the feelings, thoughts, fears and emotions when s/he first learns of the diagnosis and later as the disease further manifests itself, and as the patient struggles with decisions regarding treatment options. Learn about the emotional stages of terminal illness so well defined in Elisabeth Kubler-Ross’ book On Death and Dying. This knowledge is indispensable and will guide you to an understanding of the process and what dying patients are going through.

Listen to your patient’s concerns. What are they most worried about? You may be surprised to learn that the biggest thing most patients fear, at least in the short term, is not dying itself, but that they won’t be able to continue to do the things they’ve always been doing, whether it be playing golf, taking care of their kids, going to work at a job they enjoy, or traveling to visit their family.

Frequently, people worry about their loved ones more than about themselves. “How will they carry on after I’m gone?” You don’t have to pry to learn these things. Just be attentive when your patients talk to you and don’t deny them the ability to discuss them. They may not wish to tell their families directly what they are thinking, but it is important for them to tell someone.

Prognosis

Some patients want to know their prognosis right away, which is often difficult to predict. If you try to be too specific, you will be wrong most of the time. Many will take you very literally. For example if you say the person has six months to live, s/he may become quite anxious unnecessarily as the specific date gets closer six months later. You can give them statistics based on the medical literature, but there are wide ranges of patients that won’t follow the statistical pattern. It’s best to speak about this in general terms and only when asked directly. If they don’t ask, they probably don’t want to know.

Families

Talk to families and loved ones with the patient’s permission. Remember that the situation is difficult for them also. They are suffering from an emotional standpoint just as much as, if not more so, than the patient. They go through the same emotional stages that the dying patient goes through from a different perspective. Families want to be supportive, but sometimes don’t know how to be. They are fearful, sorrowful and grieving all at the same time. You need to be there to provide support for them, as much as for their loved one. They need to know what to expect as much as possible, what to look out for, when to call for help, when to call other family members who are out of town, etc. Spend a little time with them. Answer all their questions compassionately. They will appreciate it greatly and so will the patient.

Ways of dying

There are good ways to die and bad ways to die. If you’re expecting your patient to die imminently, try to make it a “good” death. Keep your patient comfortable. If you have a Palliative Care Team and/or Hospice Team available, use them. They are skilled at this process and can help immensely. When your patient dies, you should make it a point to call the family within the next 24 hours to express your condolences. Go to the trouble of sending a sympathy card. It means a lot to a grieving family.

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These are difficult things for all of us to face, even though we know death is paradoxically part of life and inherent in the natural order of the world. We all have to deal with it at some time or another. As physicians and healthcare professionals, we have the opportunity and the responsibility to “provide comfort when there is no cure”. Do this carefully for your patients and hopefully someone will do the same for you.